Ob-Gyn Coding Alert

Question: Our ob-gyn sees a patient for CA-125 (cancer-antigen-125), a protein found at higher levels in most ovarian cancer cells. Should I be coding V71.1 with a symptom? We do a lot of these tests, and most go through with just the V71.1, but some come back denied. Wouldn't "probable" and "suspected" be similar, assuming the physician has just cause?


Iowa Subscriber

Answer: You should never use any of the V71-category codes (Observation and evaluation for suspected conditions not found) with a symptom or complaint.

You should only use these codes when the patient has no signs or symptoms but the ob-gyn is still investigating the situation because he thinks there might be a problem. In the end, the ob-gyn finds nothing.

Rule: If the ob-gyn does not establish a diagnosis but you code it as if it were true, you have given the patient the condition even if she did not have it. This is why the rule is in place.

If the ob-gyn draws blood for the CA-125, why did he do that? Did the patient have a history that was a worry? Is he just doing it for screening? And did he know the value was elevated at the end of the visit? If not, and there was no better code to use (such as family or personal history), V71.1 (Observation for suspected malignant neoplasm) fits best.

If he knows there is an elevated CA-125 at the end of the visit, you cannot use the V71.x code but would then switch to 790.99 (Other nonspecific findings on examination of blood; other) until such time the ob-gyn confirms ovarian cancer.

The answers for Reader Questions and You Be the Coder were provided by Melanie Witt, RN, CPC, MA, an ob-gyn coding expert based in Guadalupita, N.M.